Health Release Form

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Please use a 10 digit phone number
I hereby authorize Diabetes Supply Center of the Midlands/Diabetes Education Center of the Midlands to use and/or disclose my health information as follows:
Disclose To:
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Information to be Disclosed:


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(State time period or "all")
I understand and acknowledge that:
1. My refusal to sign this authorization will not affect my ability to obtain treatment at DIABETES SUPPLY CENTER OF THE MIDLANDS.
2. Medical information to be disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer protected by State or federal law.
3. This authorization is effective for months (Type 99 for lifetime authorization) after the date it was signed. I understand that I may revoke this authorization at any time by giving written notice to Diabetes Supply Center of the Midlands. My revocation will not be effective to the extent action has already been taken in reliance on my authorization.
4. I have read (or had read to me) and have received a copy of this document.
A photocopy or exact reproduction of this signed authorization shall have the same force and effect as the original.
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You consent and agree that your use of a keypad or other device to type your name in to this form constitutes your signature, acceptance and agreement as if actually signed by you in writing.



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